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Flexible Spending Account
Summary of Selected FSA Rules:
The plan year for the Flexible Spending Account is September 1 to August 31 of
each year. Under section 125 of the IRS code, this plan helps you pay for
certain medical and child care expenses with pre-tax dollars.
Allowable Expenses:
Medical/Dental Expenses
You may apply your FSA dollars toward the following medical and dental expenses
that are not covered by your group plan:
1. The annual out of network deductible for the medical and dental plan.
2. The co-pay on doctor’s office visits and prescriptions .
3. Expenses above the annual maximum on the dental plan and procedures not
covered under the plan.
4. Eyeglasses and contact lenses and other vision care expenses not covered by
the plan.
5. Over the counter drugs that meet the definition of “medical care” such as
antacids, allergy medicine, pain relievers or cold medicine but not vitamins or
diet supplements .
6. Unreimbursed expenses of your spouse or children even if they are not covered
under our plan.
Dependent Care
You may apply your FSA dollars to Child Care expenses if both you and your
spouse work. The dependent must be under age 13 or physically or mentally
incapable of caring for himself or herself. The expense must be employment
related and cannot exceed the income of the lower paid spouse. Reimbursement for
your expenses will be sent directly to you from the plan administrator. All
money in a FSA must be used up by the end of the plan year or it will be
forfeited.
 FSA Enrollment Form
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